Cardio-oncology represents the intersection of cancer and cardiovascular disease. Cancer therapies can result in cardiovascular complications, and some patients become less attentive to their chronic disease management after a diagnosis of cancer. As cancer patients are living longer, for some, their risk of dying of cardiovascular disease exceeds their risk of dying of cancer.
Dawn L. Hershman, MD, MS, FASCO
Although much of the field of cardio-oncology has initially focused on risk and prevention of treatment-related cardiac complications, there is a growing body of evidence that both cancer and cardiovascular disease share several risk factors, including tobacco use, obesity, unhealthy diets, inactivity, and alcohol use.1 There is conflicting evidence that other cardiovascular risk factors such as diabetes, hypertension, or hyperlipidemia may contribute to cancer risk, and there is the possibility that treatment of these chronic conditions, with agents such as statins, aspirin, and antihypertensive agents, may result in a reduced cancer risk. To add further support to the interaction between cardiovascular risk factors and cancer risk, there is evidence from several large cohort studies suggesting that a healthy lifestyle or improved management of cardiovascular disease risk factors may result in a lower risk of cancer.2,3
Cardiovascular Risk Prediction Models and Cancer Risk
In clinical practice, risk models are used to identify patients at risk for coronary heart disease events, and they are meant to prompt clinician-patient discussions about lifestyle therapy and to justify the use of primary prevention medications for known cardiovascular risk factors.1 One of these risk models is the Atherosclerotic Cardiovascular Disease (ASCVD) risk score, which factors in age, gender, race, cholesterol level, blood pressure, smoking, and treatment of cholesterol or diabetes and calculates the 10-year risk of heart disease. Another risk model is the American Heart Association (AHA) Life’s Simple 7 score, which is based on modifiable risk factors and current heart health; it assesses body mass index, smoking, physical activity, diet, diabetes, hypertension, and hypercholesterolemia. Multiple studies have demonstrated an inverse relationship between adherence to these measures and cardiovascular disease outcomes.
The study recently reported in JACC:Cardio-Oncology by Lau et al—and reviewed in this issue of The ASCO Post—evaluated the association of individual cardiovascular risk factors, biomarkers known to be associated with cardiovascular risk, the ASCVD risk score, and the AHA Life’s Simple 7 score and the subsequent risk of developing cancer.4 This study looked at data from about 20,000 patients enrolled in two large prospective cohort studies who did not have any history of cancer at enrollment and compared baseline cardiovascular risk among those who did and did not develop cancer.
Both the ASCVD risk score and the Life’s Simple 7 score were associated with the development of cancer. Subjects with the highest ASCVD score had more than a threefold increased risk of cancer, and subjects with higher health scores on Life’s Simple 7, or better heart health, had a 24% lower risk of cancer development compared with those in the lowest third. Of note, although individual univariate associations were found with many of the cardiovascular risk factors, the key factors driving the association were age and smoking status, factors known to be associated with cancer. These associations may differ by cancer type.
Clinical Implications
Although the study by Lau et al focused on the risk of developing cancer, many risk mitigation strategies for cardiovascular disease may also result in improved cancer outcomes among survivors. Ongoing trials are evaluating lifestyle factors such as diet, exercise, and weight management on the risk of cancer recurrence. Other studies are evaluating the role of aspirin, metformin, and beta-blockers on cancer progression and recurrence risk. If these trials are successful, understanding the optimal strategies to implement these interventions and how to assist patients with adhering to them will be needed.
Together, heart disease and cancer represent the most common causes of death in the United States.5 From a public health perspective, the messaging to patients is quite clear. Not only can attention to lifestyle factors such as diet, weight, exercise, avoiding tobacco, and optimizing management of comorbidities reduce the risk of cardiovascular disease and stroke, but it can also reduce the risk of cancer. The AHA and ASCO have published guidelines and educational tools focusing on the most common shared risk factors—smoking cessation and obesity. However, there are many opportunities for partnerships to develop strategies to reduce the burden of chronic disease and cancer.
Dr. Hershman is Professor of Medicine and Epidemiology and Director of Breast Oncology at the Columbia University, Herbert Irving Comprehensive Cancer Center, New York, New York.
DISCLOSURE: Dr. Hershman has served as a consultant or advisor to AIM
Specialty Health.
REFERENCES
1. Koene RJ, Prizment AE, Blaes A, et al: Shared risk factors in cardiovascular disease and cancer. Circulation 133:1104-1114, 2016.
2. Rasmussen-Torvik LJ, Shay CM, Abramson JG, et al: Ideal cardiovascular health is inversely associated with incident cancer: The Atherosclerosis Risk In Communities study. Circulation 127:1270-1275, 2013.
3. Nöthlings U, Ford ES, Kröger J, et al: Lifestyle factors and mortality among adults with diabetes: Findings from the European Prospective Investigation into Cancer and Nutrition-Potsdam study. J Diabetes 2:112-117, 2010.
4. Lau ES, Paniagua SM, Liu E, et al: Cardiovascular risk factors are associated with future cancer. JACC: CardioOncology 3:48-58, 2021.
5. Weir HK, Anderson RN, Coleman King SM, et al: Heart disease and cancer deaths: Trends and projections in the United States, 1969–2020. Prev Chronic Dis 13:E157, 2016.
